1625-new_IC_PTA_MTSR_CG-11410A

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

PRIVACY THRESHOLD ANALYSIS (PTA)
This form serves as the official determination by the DHS Privacy Office to
identify the privacy compliance requirements for all Departmental uses of
personally identifiable information (PII).
A Privacy Threshold Analysis (PTA) serves as the document used to identify
information technology (IT) systems, information collections/forms, technologies,
rulemakings, programs, information sharing arrangements, or pilot projects that involve
PII and other activities that otherwise impact the privacy of individuals as determined by
the Chief Privacy Officer, pursuant to Section 222 of the Homeland Security Act, and to
assess whether there is a need for additional Privacy Compliance Documentation. A PTA
includes a general description of the IT system, information collection, form, technology,
rulemaking, program, pilot project, information sharing arrangement, or other Department
activity and describes what PII is collected (and from whom) and how that information is
used and managed.
Please complete the attached Privacy Threshold Analysis and submit it to your
component Privacy Office. After review by your component Privacy Officer the PTA is sent
to the Department’s Senior Director for Privacy Compliance for action. If you do not have a
component Privacy Office, please send the PTA to the DHS Privacy Office:
Senior Director, Privacy Compliance
The Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
Tel: 202-343-1717
PIA@hq.dhs.gov

Upon receipt from your component Privacy Office, the DHS Privacy Office will review this
form and assess whether any privacy compliance documentation is required. If compliance
documentation is required – such as Privacy Impact Assessment (PIA), System of Records
Notice (SORN), Privacy Act Statement, or Computer Matching Agreement (CMA) – the DHS
Privacy Office or component Privacy Office will send you a copy of the relevant compliance
template to complete and return.
Privacy Threshold Analysis – IC/Form

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Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

Privacy Threshold Analysis (PTA)

Specialized Template for
Information Collections (IC) and Forms
The Forms-PTA is a specialized template for Information Collections and Forms.
This specialized PTA must accompany all Information Collections submitted as part of the
Paperwork Reduction Act process (any instrument for collection (form, survey,
questionnaire, etc.) from ten or more members of the public). Components may use this
PTA to assess internal, component-specific forms as well.

Form Number:

CG11410A

Form Title:
Component:

Marine Transportation System Recovery Facility Status
U.S. Coast Guard (USCG) Office:
Atlantic Area (L-544)

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
OMB Control
Number:
Collection status:

Name:
Office:
Phone:

Marine Transportation System Recovery Essential Elements of
Information
MM/DD/YYY
1625-NEW
OMB Expiration
Date:
New collection
Date of last PTA (if
N/A
applicable):

PROJECT OR PROGRAM MANAGER
Timothy Mann
Atlantic Area (L-544)
Title:
Port Security Specialist
850-279-6372
Email:
Timothy.F.Mann@uscg.mil

Privacy Threshold Analysis – IC/Form

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

Name:
Office:
Phone:

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Anthony Smith
CG-612
Title:
PRA Manager
202-475-3532
Email:
anthony.d.smith@uscg.mil
SPECIFIC IC/Forms PTA QUESTIONS

1. Purpose of the Information Collection or Form
a. Describe the purpose of the information collection or form. Please provide a general
description of the project and its purpose, including how it supports the DHS mission, in
a way a non-technical person could understand (you may use information from the
Supporting Statement).
If this is an updated PTA, please specifically describe what changes or upgrades are
triggering the update to this PTA.
Following a port disruption (natural causes or man-made) the USCG will gather post-disruption
information from waterfront businesses in the affected area. The CG uses this data to measure
the disrupted condition of the port against the normal baseline to provide critical input to those
federal, state, and local response organizations that are engaging in restoring the port to its predisruption condition. This information also enables the USCG to assist in prioritizing recovery
efforts and to gauge the effectiveness of the response.
b. List the DHS (or component) authorities to collect, store, and use this information. If
this information will be stored and used by a specific DHS component, list the componentspecific authorities.
USCG Authorities: 33 U.S.C. §1225, 46 U.S.C. §70103, and 50 U.S.C. §191.
2. Describe the IC/Form
a. Does this form collect
any Personally
Identifiable
Information” (PII 1)?
b. From which type(s) of
individuals does this
form collect

x Yes
☐ No
x Members of the public
x U.S. citizens or lawful permanent residents
☐ Non-U.S. Persons.

1
Personally identifiable information means any information that permits the identity of an individual to be directly or indirectly inferred,
including any other information which is linked or linkable to that individual regardless of whether the individual is a U.S. citizen, lawful
permanent resident, visitor to the U.S., or employee or contractor to the Department.

Privacy Threshold Analysis – IC/Form

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

information? (Check all
that apply.)
c. Who will complete and
submit this form?
(Check all that apply.)

d. How do individuals
complete the form?
Check all that apply.

☐ DHS Employees
☐ DHS Contractors
☐ Other federal employees or contractors.

☐ The record subject of the form (e.g., the individual
applicant).
☐ Legal Representative (preparer, attorney, etc.).
x Business entity.
If a business entity, is the only information
collected business contact information?
x Yes
☐ No
☐ Law enforcement.
☐ DHS employee or contractor.
☐ Other individual/entity/organization that is NOT
the record subject. Please describe.
Click here to enter text.

x Paper.
x Electronic. (ex: fillable PDF)
x Online web form. (available and submitted via the
internet)
Provide link:
https://cg.portal.uscg.mil/units/lantarea/lant5/LANT54/LANT544/LANT544%20Documents/MTS%2
0Recovery/CG11410A.pdf

e. What information will DHS collect on the form? List all PII data elements on the form.
If the form will collect information from more than one type of individual, please break
down list of data elements collected by type of individual.
Facility status related information and business point of contact information: name (i.e. work
telephone, and work email information). This information is requested on a voluntary basis.
There is no regulatory requirement compelling the business to provide the information.
f. Does this form collect Social Security number (SSN) or other element that is standalone Sensitive Personally Identifiable Information (SPII)? N/A.
☐ Social Security
number

Privacy Threshold Analysis – IC/Form

☐ DHS Electronic Data Interchange Personal Identifier
(EDIPI)
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

☐ Alien Number (ANumber)
☐ Tax Identification
Number
☐ Visa Number
☐ Passport Number
☐ Bank Account, Credit
Card, or other financial
account number
☐ Other. Please list:

☐ Social Media Handle/ID
☐ Known Traveler Number
☐ Trusted Traveler Number (Global Entry, Pre-Check,
etc.)
☐ Driver’s License Number
☐ Biometrics

g. List the specific authority to collect SSN or these other SPII elements.
N/A.
h. How will this information be used? What is the purpose of the collection? Describe
why this collection of SPII is the minimum amount of information necessary to
accomplish the purpose of the program.
N/A.
i. Are individuals
x Yes. Please describe how notice is provided.
provided notice at
The form is marked with a Privacy Act Statement on the
the time of
bottom. IT is clearly visible to the business POC who is
collection by DHS
voluntarily providing the information.
(Does the records
☐ No.
subject have notice of
the collection or is
form filled out by
third party)?

3. How will DHS store the IC/form responses?
a. How will DHS store
☐ Paper. Please describe.
the original,
Click here to enter text.
completed IC/forms?
x Electronic. Please describe the IT system that will

store the data from the form.
Only the facility information is stored in a CG data base
(CART, Common Assessment Reporting Tool)
accessible to USCG personnel and other Federal agency

Privacy Threshold Analysis – IC/Form

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

personnel with a need to know following a port
disruption. The business POC information is not stored
in the data bank. The POC information is only used
upon receipt of the post disruption data to allow the CG
to ask follow-up questions (if necessary) prior to entry of
the facility info into the data base. ☐ Scanned forms
(completed forms are scanned into an electronic
repository). Please describe the electronic repository.
b. If electronic, how
does DHS input the
responses into the IT
system?

x Manually (data elements manually entered). Please
describe.
A port recovery planner inputs the facility data
manually and saves it as the Ports Baseline data.

c. How would a user
search the
information
submitted on the
forms, i.e., how is the
information
retrieved?

☐ By a unique identifier. 2 Please describe. If
information is retrieved by personal identifier, please
submit a Privacy Act Statement with this PTA.
Click here to enter text.
x By a non-personal identifier. Please describe.

d. What is the records
retention
schedule(s)? Include
the records schedule
number.
e. How do you ensure
that records are
disposed of or deleted

☐ Automatically. Please describe.
Click here to enter text.

Information is retrieved by the facility/ business
name.
NARA retention schedule number N1-026-05-015.

As records are maintained in the CART database,
disposal/deletion is in accordance with the business rules for
the database.

2
Generally, a unique identifier is considered any type of “personally identifiable information,” meaning any information that permits the identity
of an individual to be directly or indirectly inferred, including any other information which is linked or linkable to that individual regardless of
whether the individual is a U.S. citizen, lawful permanent resident, visitor to the U.S., or employee or contractor to the Department.

Privacy Threshold Analysis – IC/Form

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

in accordance with
the retention
schedule?
f. Is any of this information shared outside of the original program/office? If yes,
describe where (other offices or DHS components or external entities) and why.
What are the authorities of the receiving party?
x Yes, information is shared with other DHS components or offices. Please describe.

Only facility status information is shared-no PII information from the business POC is
retained in the data base.

x Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.

Only facility status information is shared-no PII information from the business POC is
retained in the data base. Information is only shared with Federal, State, and local
agencies with a need to know following a port disruption.
☐ No. Information on this form is not shared outside of the collecting office.

Please include a copy of the referenced form and Privacy Act Statement (if
applicable) with this PTA upon submission.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

PRIVACY THRESHOLD REVIEW
(TO BE COMPLETED BY COMPONENT PRIVACY OFFICE)
Component Privacy Office
Reviewer:
Date submitted to component
Privacy Office:
Date submitted to DHS Privacy
Office:
Have you approved a Privacy Act
Statement for this form? (Only
applicable if you have received a
waiver from the DHS Chief Privacy
Officer to approve component
Privacy Act Statements.)

Kenlinishia Tyler
October 4, 2016

October 26, 2016

☐ Yes. Please include it with this PTA
submission.
X No. Please describe why not.
This form has been in previous existence.
The PAS can be found at the bottom of the
form.

Component Privacy Office Recommendation:
CG-Form 11410A (i.e. Marine Transportation System Recovery Facility Status) is used to
determine the status of a waterfront business/facility following a man-made or natural
disaster. USCG uses this information to prioritize recovery efforts, gauge response
effectiveness and measure the disrupted condition of a port against the normal baseline in
order to provide critical input to those entities (e.g. federal, state, or local response
organizations) responsible for restoring the port to its previous condition.
Authorized USCG officials input waterfront business/facility data into the Common
Assessment Reporting Tool (CART) which is only accessible to USCG personnel and
federal agency personnel with a need to know.
This collection is covered by DHS/USCG/PIA-022 and DHS/USCG-013.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

PRIVACY THRESHOLD ADJUDICATION
(TO BE COMPLETED BY THE DHS PRIVACY OFFICE)
DHS Privacy Office Reviewer:

Michael Capparra

PCTS Workflow Number:
Date approved by DHS Privacy
Office:
PTA Expiration Date

1134045
November 3, 2016

November 3, 2019

DESIGNATION
Privacy Sensitive IC or
Form:
Determination:

Yes. If “no” PTA adjudication is complete.
☐ PTA sufficient at this time.

☐ Privacy compliance documentation determination in progress.
☐ New information sharing arrangement is required.

☐ DHS Policy for Computer-Readable Extracts Containing SPII
applies.
☒ Privacy Act Statement required.

☒ Privacy Impact Assessment (PIA) required.

☒ System of Records Notice (SORN) required.
☐ Specialized training required.

☐ Other. Click here to enter text.
DHS IC/Forms Review: DHS PRIV has approved this ICR/Form.
Date IC/Form
November 3, 2016
Approved by PRIV:
1134045
IC/Form PCTS
Number:
Privacy Act
Choose an item.
Statement:
Click here to enter text.
PTA:
Choose an item.

Privacy Threshold Analysis – IC/Form

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

PIA:

System covered by existing PIA
If covered by existing PIA, please list: DHS/USCG/PIA-022 Coast Guard
Maritime Information eXchange, July 2015
If a PIA update is required, please list: Click here to enter text.
SORN:
System covered by existing SORN
If covered by existing SORN, please list: DHS/USCG-013 - Marine
Information for Safety and Law Enforcement (MISLE)
If a SORN update is required, please list: Click here to enter text.
DHS Privacy Office Comments:
Please describe rationale for privacy compliance determination above.
The DHS Privacy Office finds that the Marine Transportation System Recovery Essential
Elements of Information form, which collects business contact information (including
related PII) in order to determine the status waterfront businesses and facilities following
a man-made or natural disaster, represents a privacy sensitive collection of information
and requires both PIA and SORN coverage. The form contains a Privacy Act statement. PIA
coverage is provided DHS/USCG/PIA-022 Coast Guard Maritime Information eXchange,
which describes the Coast Guards use of PII as part of its provision of maritime-related
information the public, as well as federal, state, and local governments. SORN coverage is
provided by DHS/USCG-013 - Marine Information for Safety and Law Enforcement
(MISLE), which outlines the Coast Guard’s collection and maintenance of safety, security,
and law enforcement performance history of vessels, facilities, people and organizations
engaged in marine transportation, including enforcement action, that can be used to
identify and address safety, security and environmental risks and to establish vessel
eligibility for documentation as a U.S. flag vessel.

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